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Feeling Strain When Violent Patients Need Care

I didn’t know much about the patient — just that he’d showed up on my floor the previous evening after some confusion about whether his room was ready. When I went into his room that morning, he was still asleep. I gently roused him while his doctor, who had followed me in, explained that he needed to do a physical exam.

The patient, suddenly fully awake, challenged him: “Are you going to examine me or are you just going to stand there and talk about it?”

He was aggressive, confrontational. But more than that, his voice had an edge to it that, I’ll reluctantly admit, scared me, especially when he quickly got up out of the bed and started yelling at the doctor and me. He was a big guy, weighing almost 300 pounds, muscular, and taller than I am.

The doctor quickly left, saying he was going to call security. The patient then focused on me: “Look at you, standing there with that stupid look on your face.”

What was happening here?

Turns out the patient had a history of being violent in the hospital, and there had been resistance to admitting him at all.

A contingent from security and administration came up and had him sign a behavioral contract. That sounded good to me, except that the behavioral expectations, and the consequences of defying them, remained undefined. “He has to behave,” the administrator in charge said when I asked her to explain the terms.

They left a guard outside the room, but he sat about 30 feet away, because having the guard closer agitated the patient. Nursing work often requires physical closeness: listening to a patient’s breathing, checking a pulse, administering IV drugs. If the patient became violent, the guard would not have been able to arrive in time to save me.

The day became a nightmare, as employee after employee told me one scary story after another about my already frightening patient.

“Is that the guy who punched a family member at the nurse’s station?”

“I heard he pulled a light fixture off the wall.”

“I saw him throw off an entire contingent of security guards.”

During a previous stay, he threatened to kill a nurse on another floor, and the police had come. He was not allowed on that floor of the hospital by court order, but he was a patient on ours. My other patients, whose rooms were all clustered in the same area, had seen the activity and asked me what was going on.

The thing is, he needed to be our patient, or at least he needed to be a patient somewhere. Security had asked me if he could safely leave the hospital. The answer, truly, was no. Sooner rather than later, his cancer would make him very sick. He needed treatment, but the challenge was caring for him without terrifying, or injuring, the staff.

“Are you safe?” We heard that question over and over again in nursing school, and at first I didn’t get it. I’m sensible, I thought; how could I not be practicing safely? But over time I understood how easy it is to accidentally hurt a patient. Pain control with narcotics can lead to respiratory depression. A common dose of blood pressure medicine might render an already sick patient dangerously hypotensive. The longer urinary catheters and breathing tubes are left in, the more likely they are to cause infections.

“Safe” becomes a mantra that embodies a set of values, and “that’s not safe” is a warning phrase among nurses that can address staffing issues, medication questions, or decisions like whether a patient should be allowed to stroll to another floor, because he is frail or easily confused, or because of the IV medication he is getting.

With this patient I felt personally threatened — unsafe — which made me feel scarily distracted.

Unfortunately, I’m not alone among nurses in feeling at risk. According to the American Nurses Association 2011 Health and Safety Survey, the proportion of registered nurses who rank “on-the-job assault” as one of their three greatest safety concerns is now at 34 percent, up from 25 percent in 2001. The percentage of nurses who reported actually being assaulted on the job declined in that time — to 11 percent last year from 17 percent in 2001 — but still, more than half of all R.N.’s have been verbally threatened at work.

More sobering, government statistics show that from 2003 to 2009, eight nurses were killed at work, and in 2009, 2,050 incidents involving harassment or violent assault were reported by clinical nurses.

The most accurate way to describe my patient was “menacing,” and the strain of caring for him made it difficult to focus on my work. That afternoon, after I gave him a saline nose spray, he said, “I don’t like your face,” and a member of his care team, seeing how agitated I was, assigned a different nurse — a man — to take care of him.

I felt relieved, but also humiliated. In the hospital, there’s a sense that employees who react to being threatened are not tough enough. A parallel narrative about the patient was also circulating, offered by consulting clinicians who knew him from previous admissions: He’d had a hard life; he was really a good guy.

I’m sure there was truth in those claims, but I like to think I don’t scare that easily, and this guy scared me. The most comfort I got was “He’s never physically assaulted a staff member,” which was not exactly comforting.

After all, it’s my job to take care of patients, to keep them safe — this patient included. But I discovered it’s very hard to do that if I don’t feel safe myself.